What is the most common presentation of testicular cancer?

Most Common Presentation of Testicular Cancer

The most common presentation of testicular cancer is a painless testicular nodule or mass, which should be further evaluated with transscrotal ultrasound with Doppler to confirm the diagnosis 1.

Clinical Presentations of Testicular Cancer

• Painless testicular mass/nodule/enlargement - This is the classic and most common presentation of testicular cancer 1
• Painful testicular mass - While less common, testicular cancer can sometimes present with pain 1
• Testicular induration (hardening) - Another presentation that warrants further investigation 1
• Scrotal pain - Present in approximately 27% of cases 1
• Back or flank pain - Present in approximately 11% of cases, typically indicating more advanced disease 1
• Gynecomastia - Present in approximately 1% of cases 1

Diagnostic Approach

When a testicular mass is detected, the following diagnostic algorithm should be followed:

1. Transscrotal ultrasound with Doppler - This is the primary diagnostic tool to confirm the presence of an intratesticular mass 1, 2

   • Should use a high-frequency (>10 MHz) probe 1
   • Allows evaluation of contralateral testicular volume and presence of synchronous tumors 1

2. Serum tumor markers - Should be measured before orchiectomy 1, 2

   • Alpha-fetoprotein (AFP)
   • Beta-human chorionic gonadotropin (β-hCG)
   • Lactate dehydrogenase (LDH)

3. Radical inguinal orchiectomy - Provides definitive histological diagnosis 1, 2

   • Should be performed via inguinal approach, never scrotal 2
   • Should be done before any further treatment unless immediate chemotherapy is required 1

Important Clinical Considerations

• Testicular cancer primarily affects young men between 20-34 years of age 1, 3
• Approximately 95% of testicular cancers are germ cell tumors (GCTs) 1, 3
• Risk factors include cryptorchidism, family history of testicular cancer, and infertility 1, 3
• Delay in diagnosis correlates with higher stage at presentation 2
• Approximately 55-60% of GCTs are pure seminomas and 40-45% are non-seminomas 1

Common Pitfalls to Avoid

• Delaying evaluation of a testicular mass, as early diagnosis significantly improves outcomes 2, 3
• Performing scrotal approach for suspected testicular tumors, which is associated with higher local recurrence rates 2
• Assuming normal tumor markers exclude GCT - Tumor markers have low sensitivity, especially in seminoma 1
• Confusing with other conditions - Testicular masses should be differentiated from epididymitis, orchitis, hydrocele, varicocele, and inguinal hernia 4, 5

Differential Diagnosis of Testicular Masses

• Testicular cancer (seminoma or non-seminoma) 1
• Inguinal hernia 4
• Varicocele 4
• Hydrocele 6
• Epididymitis/orchitis 5
• Testicular torsion 4, 5

Remember that any testicular mass should be considered malignant until proven otherwise 6, 7, 8.